General Approach to Patients Presenting with Behavioural Complaints

Overall, the approach to patients presenting with behavioural complaints should be the same as the approach to those with general medical Episode 85 – Medical Clearance of the conditions: ABCs, a thorough history (including collateral history) and Psychiatric Patient physical, selected tests. History and physical exam remain the main stay of evaluation; the With Dr. Howard Ovens, Dr. Ian Dawe & Dr. minimum data set should include full vital signs, history including Brian Steinhart history of mental illness, medications, substances, mood and thought Prepared by Dr. Anton Helman, August 2016 content, mental status exam and further examination as indicated by

presentation, vital signs and history.

We Shouldn’t be Calling it Medical Clearance of the A 1997 study by Olshaker et al. of 345 patients presenting to an ED with Psychiatric Patient! psychiatric complaint, a complete history was the most sensitive for identifying a common medical condition at 94% compared to physical Medical clearance isn’t a term to represent the absence of medical and lab tests. issues, but rather the absence of medical instability or a medical If you are unable to obtain a history from an altered patient, the risk for condition causing or contributing to the behavioural presentation. missing an important medical illness goes up significantly. Since it’s not possible to screen and diagnose all potential concurrent medical illnesses in the ED, some experts prefer the terms “evaluation Historical Clues to Help Differentiate Organic vs for medical stability,” or “focused medical assessment of the altered Psychiatric Illness patient”. When patients are labelled as “psychiatric” or “functional”, we Patients who present with altered level of awareness or a dramatic tend to bias our assessment of them. change in their behaviour often end up getting extensive expensive

workups that could be avoided by asking patients a few simple questions. These questions may help reveal an obvious cause for their altered behaviour early on in your assessment, including Somatoform • onset over hours-days Disorders: • complaint of headache Where do you live? • any recent new medication Who do you live with? How do you support yourself? A detailed extensive mental status exam is not necessary in every patient Do you have any outstanding charges you’re facing? with a behavioural problem. A study out of the Annals of EM showed Have you ever been in jail? that The Quick Confusion Scale is as reliable as a full Mini-Mental What substances do you regularly use? Status Exam to reveal an altered level of awareness that may help pick Where were you just before you came to the ED? up organic pathology:

The Quick Confusion Scale It is imperative that you take the time to ask these questions and give the What month is it? patient time to answer them, which may seem at face value to take too Repeat phrase and remember it: “John Brown, 42 Market Street, New York” much time in a busy ED, but will minimize the chances of missing a About what time is it? significant medical diagnosis as well as prevent a time-consuming Count backward from 20 to 1 extensive work-up later on and ultimately is the most efficient way to Say the months in reverse Repeat the memory phrase arrive at a diagnosis.

Factors favouring psychiatric illness The 3 key elements of the mental status exam are orientation, memory

• history of psychiatric illness and judgment which can often be gleaned from the patient encounter by an experienced EM provider without a validated scale. • younger age • onset over weeks to months

Factors favouring organic illness

• no history of psychiatric illness • older age (>40) Physical Exam Clues to Differentiate Organic vs Take a moment to look up the nares of the patient’s nose; you might be Psychiatric Illness surprised to find cocaine, crushed buproprion or any number of toxins that the patient has insufflated. As always, vital signs are vital! Any abnormality in vital signs should be addressed and accounted for. Visual hallucinations usually point to an organic illness. Generally Hypoglycemia can mimic many psychiatric illnesses from catatonic speaking, auditory hallucinations are more indicative of a psychiatric schizophrenia to severe depression as should be considered as “the 6th illness where as visual hallucinations are more indicative of an organic vital sign”. illness. While about 15% of patients with schizophrenia are said

to experience visual hallucinations, these tend to occur in those Blood glucose (ABC Don’t Ever Forget Glucose) schizophrenics with severe illness in addition to auditory hallucinations.

Look for fluctuating level of awareness as it is rare in Which Psychiatric Patients Require Screening Lab isolated psychiatric illness, and often signifies delirium and an Tests or CT Scan of the Head underlying toxin, metabolic abnormality or CNS lesion.

Scrutinize the patient’s eyes – any abnormality in gaze, nystagmus, pupillary dilation etc may signify an organic pathology.

Dr. Steinhart’s trick of the trade for assessing nuchal rigidity from the end of the bed: While the patient is standing, have them fixate on a coin and then toss the coin on the floor at their feet. If they flex their neck through a full range of motion to look down at the coin, it makes it less likely that they have meningismus.

Ask the patient to protrude their tongue. If you see a laceration, think about a post-ictal state as a cause for their altered behaviour.

No lab test screening required 91%. The reliability of self-reported alcohol use was 96% sensitive and There is no evidence-based list or panel of investigations or order set 87% specific. In addition, urine drug screens have many false positive that can be applied to all psychiatric patients requiring medical and negatives which can be misleading. clearance. ACEP guidelines on routine urine drug screen ACEP recommends screening tests for: s for psychiatric patients: “Routine urine toxicology screens for drugs of abuse in patients who are alert, awake, and cooperative do not affect ED 1. patients who have new-onset psychiatric complaints, management and should not be performed as part of the ED assessment. 2. those with abnormal vital signs, the elderly, and Additionally, toxicology screens obtained in the ED for use by the 3. those with a known or suspected co-morbid condition receiving psychiatric facility or service should not delay patient evaluation or transfer. (Level C recommendation).” However, our experts recommend, that in the patient who presents with classic uncomplicated schizophrenia with normal vital signs and an Pitfalls in the medical assessment of psych patients otherwise normal physical exam (even if it is a first time presentation), a 1. Incomplete history, including failure to obtain ancillary CT Head is not indicated as the yield of a clinically significant finding information. on a CT Head in this patient population was found in a preliminary 2. Cursory physical without full vitals, mental status exam, brief study in 3 Ontario hospitals to be 1 in 300. Another review of 5 neurologic exam and assessment for toxidromes. 3. Premature closure of a psychiatric diagnosis. studies from 2009 showed that of 384 CT and 184 MRI scans of first 4. Indiscriminate lab and imaging testing. episode psychosis patients the diagnostic yield was only 1.3% for CT and 1.1% for MRI scans. Literature Summary on Routine Lab Test Screening of Psychiatric Patients in the ED CT is clinically indicated in psychiatric patients with altered mental status, trauma, immunodeficiency, or focal neurological findings. Paper #1: 1997 Academic EM – screening without routine lab testing Urine drug screens are not required routinely in the psychiatric patient. would have missed 2 out of 352 asymptomatic hypokalemia Most patients, if asked in a non-accusatory manner, will tell you what patients. Most medical problems and substance abuse were identified by drugs they have recently taken. Olshaker found that the reliability of abnormal vital signs and history and physical examination. patient self-reported drug use had a sensitivity of 92% and specificity of Paper #2: 2000 Journal of EM – in this retrospective chart review of Paper #6 in a retrospective observational study by Olshaker and 212 patients none had positive screening lab results. The authors colleagues in which the history and physical exam had a sensitivity of concluded that “a patient who denied current medical problems and who 94% and 51%, respectivel in identifying medical illness in psychiatric presented with a primary psychiatric complaint, documented psychiatric patients. Laboratory testing had a sensitivity of only 20%. history, stable vital signs, and normal physical examination findings could be referred for psychiatric evaluation without additional testing.” 3 Main Take Home Points in Medical Clearance of the Psychiatric Patient Paper #3: 2012 Journal of EM – in this retrospective chart review of 1. Approach to psychiatric patients should be the same as your 519 patients there was one case in which an abnormal lab value would approach to any medical patient – an adequate history and have changed ED management or disposition. physical is essential.

2. Know which patients are at high risk for an organic cause of Paper #4: In a study by Hall, 100 patients admitted to a psychiatric their behavioural presentation so that you have a heightened facility all had electrolytes, electrocardiogram, electroencephalogram, awareness for organic pathology in these patients. urine drug screen, and urinalysis performed. Of the 100 patients, 46% 3. There is no evidence for benefit of routine screening exams – had unrecognized medical illnesses and 80% of those needed treatment, tests should be done as you would a medical patient – pertinent however the vast majority of these were trivial non-urgent illnesses. to the presenting complaint and findings on a good history and

physical. Paper #5 In a retrospective study performed by Tintinali and colleagues, 298 charts of emergency voluntary psychiatric admissions were reviewed. Twelve (4%) of those patients had an acute medical condition that required intervention. In each of these cases, the history and physical was deficient and did not identify the acute medical condition.

References Shah SJ, Fiorito M, Mcnamara RM. A screening tool to medically clear psychiatric

Santillanes G, Donofrio JJ, Lam CN, et al. Is medical clearance necessary for patients in the emergency department. J Emerg Med. 2012;43(5):871-5. pediatric psychiatric patients? J Emerg Med 2014;46:800–7. Tintinalli JE, et al. Emergency medical evaluation of psychiatric patients. Ann

Weiss AP, Chang G, Rauch SL, et al. Patient- and practice- related determinants of Emerg Med. 1994 Apr;23(4):859-62. emergency department length of stay for patients with psychiatric illness. Ann Gregory RJ, Nihalani ND, Rodriguez E. Medical screening in the emergency Emerg Med 2012;60:162–71.e5. department for psychiatric admissions: a procedural analysis. Gen Hosp Psychiatry Huff JS, Farace E, Brady WJ, Kheir J, Shawver G. The quick confusion scale in the 2004;26:405–10. ED: comparison with the mini-mental state examination. Am J Emerg Med. Goulet K, Deschamps B, Evoy F, Trudel JF. Use of brain imaging (computed 2001;19(6):461-4. tomography and magnetic resonance imaging) in first-episode psychosis: review and Karas S. Behavioral emergencies: differentiating medical from psychiatric disease. retrospective study. Can J Psychiatry. 2009;54(7):493-501. Emerg Med Pract 2002;4:1–18. Donofrio JJ, Santillanes G, Mccammack BD, et al. Clinical utility of screening Olshaker JS, Browne B, Jerrard DA. Medical clearance and screening of laboratory tests in pediatric psychiatric patients presenting to the emergency psychiatric patients in the emergency department. Acad Emerg Med 1997;4:124–8. department for medical clearance. Ann Emerg Med. 2014;63(6):666-75.e3. Janiak BD, Atteberry S. Medical clearance of the psychiatric patient in the Shihabuddin BS, Hack CM, Sivitz AB. Role of urine drug screening in the medical emergency department. J Emerg Med. 2012;43(5):866-70. clearance of pediatric psychiatric patients: is there one?. Pediatr Emerg Care. Lukens T, Wolf S, Edlow J, et al. Clinical policy: critical issues in the diagnosis and 2013;29(8):903-6. management of the adult psychiatric patient in the emergency department. Ann Amin M, Wang J. Routine laboratory testing to evaluate for medical illness in Emerg Med 2006;47:79 –99. psychiatric patients in the emergency department is largely unrevealing. West J Olshaker JS, Browne B, Jerrard DA, Prendergast H, Stair TO. Medical clearance Emerg Med. 2009;10(2):97-100. and screening of psychiatric patients in the emergency department. Acad Emerg Henneman PL, Mendoza R, Lewis RJ. Prospective evaluation of Emergency Med. 1997;4(2):124-8. Department medical clearance. Ann Emerg Med 1994 24(4):672-7.

Korn CS, Currier GW, Henderson SO. “Medical clearance” of psychiatric patients without medical complaints in the Emergency Department. J Emerg Med. 2000;18(2):173-6.